Diminishing Patient Face Time in Residencies and Patient Centered Care

Saturday, January 27, 2018

Diminishing Patient Face Time in Residencies and Patient-Centered Care

Ami Schattner, MD , Steven R. Simon, MD, MPH

(The American Journal of Medicine, Vol. 112, Issue
7)

One of the more important recommendations coming from the Institute of Medicine's seminal report on medical
errors was the pressing need to implement patient-centered medical care. Although emphatically endorsed and
highly influential, adoption of its 6 dimensions in “real life” has been slow, uncommon, and imperfect in most
settings studied.

Considering how residents spend their time in training, the absence of patient centeredness in our health
systems is not surprising. Time-motion studies have emerged as a promising tool in the analysis of how the
hours of a resident's workday are actually divided.1 Other methods seem more prone to bias. Our literature
review revealed 3 such time-motion studies that characterized ≥72 hours of total recorded time among
residents. All studies were conducted in academic medical centers in the United States or Canada after the
Accreditation Council for Graduate Medical Education published new regulations limiting residents' working
hours to 80 per week (2003) and ≤16 continuous working hours (2011). Block et al2 found that internal medicine
residents spent 12% of their time in direct patient care versus 40% of their time using the computer and 15% on
educational activities. Fletcher et al3 studied first-year residents rotating on the general medicine ward who were
on call, yielding remarkably similar results: 12% of the time was spent on direct patient care and 40% on
computer work, whereas education was limited to just 2% of on-call time. Mamykina et al4 recently examined
residents' “typical work day” schedules and found that interacting with patients constituted 9% of the work day
(67.8 minutes) compared with 51% spent on computer work and 11% on rounds. Because “rounds” nowadays
are frequently conducted at the conference table and not at the patient's bedside, residents' time spent in direct
patient interaction amounted to a mere 7.7 ± 5.8 minutes per patient2 or slightly more.3 Learning activities also
are meager: In one study, just 5.8 minutes per 12-hour shift were devoted to looking up information.4

These data are appalling, especially when contrasted with the classic, often quoted, and widely lauded
teachings of Sir William Osler, Francis Peabody, and psychiatrist George Engel. All stressed “hands-on” patient
contact, patient-centeredness, and incorporation of each patient's psychosocial factors as essential in health
care delivery.

These precious few minutes that residents spend with patients can never suffice to fulfill even part of the
obligatory Institute of Medicine domains, such as understanding the patient's preferences and concerns,
meeting informational needs and promoting health literacy, and providing emotional support.5 None of these
domains should be regarded as limited to ambulatory care. Hospitalized patients' needs are comparable, and
the increasing age, prevalent multiple chronic conditions, and growing complexity of admitted patients make the
brief time devoted to face-to-face patient care even more poignant. The meager time spent by residents with
patients also is at odds with patients' wishes, even their ethical rights, and counter to the aim of improving the
patient's “experience of care.”5

Whether the studies2, 3, 4 mentioned may be applied more generally remains an open question. Nevertheless, the
consistency of the findings supports broad validity, and in fact, even less direct interaction with patients may
take place in less academic environments such as community hospitals. Moreover, similar findings were
recorded in older studies6 and could have further deteriorated because of increasing reliance on computers for
data collection, data entry, and communication, as well as decreasing residents' time on the wards following the
current work-hour regulations.

Thus, with dangerously diminishing patient contact and increasing dependence on laboratory and imaging data
printouts, the practice of medicine is jeopardized and so are our patients and their rights, safety, and health

outcomes, which correlate with a patient-centered approach.Do our patients really want to be treated by board-certified hospitalists and primary care physicians whose total supervised patient exposure was so sparse? Would we let a commercial pilot take responsibility of an aircraft after an hour per day of actual flying experience?

“Hands-on” patient care is not the sole inadequacy. The high road to improved health outcomes requires physician–patient relationship and bonding, patient satisfaction, trust, and patient activation and engagement by the physician.7 Certainly, the delivery of health care needs to be scientifically correct; however, the training of physicians must nurture curiosity about the patient,8 getting the patient's “story,”9 understanding prevalent and influential “nonmedical” factors (emotional, contextual) and the patient's preferences, and providing information, health literacy, and sincere empathy.10 These essential components of professional care can never be accomplished with only a few minutes allotted for the face-to-face engagement with patients in addition to looking up patient data, order entry, and documentation via the computer. The flimsy resident–patient contact creates an impossible time constraint, and its quality is often further degraded by multitasking4 and the fleeting attention given to worried family members.2, 7

The short time spent with patients has adverse effects on residents too. In contrast with human interaction, which fulfills the foundational desire of physicians to care and to heal, interacting primarily with a computer does not offer much gratification; frustration mounts and work-life satisfaction deteriorates. This combined with the prevalent multitasking and the paucity of time devoted to stimulating new learning experience contributes to the high and unchanging prevalence of burnout, fatigue, and depression among residents (75%, 59%, and 20%, respectively),11, 12 which seem to develop much earlier in physicians' careers than before. Physicians' well-being is threatened and repercussions include not only residents' poor quality of life but also increased errors and lower quality of care.12

Ensuring more time with the patients and improving the depth and quality of the physician–patient interaction are essential to the training of our physicians. Addressing these gaps in training is particularly urgent, because habits and attitudes acquired during residency will form the basis of future practice style. A recent time-motion study in ambulatory practice exposed that electronic health record and desk work consume nearly double the time of direct patient care.13

A national leadership move is urgently needed to return residents to the bedside and resuscitate the patient- centered and physician-enriching clinical encounter. Improved resident wellness may be an important by- product.8 We suggest a 3-pronged approach based on education, mindfulness, and evaluation. First, residents may need to be better educated on the primacy of the personal clinical encounter with their patient and the myriad benefits of a comprehensive, patient-centered approach that cannot be gleaned from any computer screen.8 Arguably, residents in medicine, pediatrics, and family practice should accumulate and document a minimum quota of new patient admissions to qualify for board certification, just as surgeons must perform and document a minimum number of independent operations. Second, in the spirit of mindfulness14 as part of the traditional admission process, residents should be encouraged to meditate and identify and record a unique personal aspect they noticed in their patient, adding a brief comment on their reaction and feelings and the implications for the future care of the patient. Attending physicians should prompt residents to discuss this personal feature, gleaned from a careful history and examination, on rounds. Finally, to reiterate the integral importance of person–person interaction during the encounter, patients should be routinely asked to evaluate their experience and satisfaction, with emphasis on residents' sensitivity, attention, grasp of the patient's concerns, and empathy. This feedback will be independently gathered and provided to residency program directors, who can use it in formative evaluation. Such an approach may be an easily implemented and cost- effective way to reiterate the unique and central role of the patient's point of view and of direct high-quality patient-centered care in the training of our future generation of physicians.

4. Mamykina, L., Vawdrey, D.K., and Hripcsack, G. How do residents spend their shift time? A time and motion study with a particular focus on the use of computers. Acad Med. 2016; 91: 827–832View in Article | Crossref | PubMed | Scopus (12)